Greater Lincolnshire

Coroner Area
Reports: 67 Earliest: Aug 2013 Latest: 1 Apr 2026

55% response rate (below 63% average).

Response Status
Responded 37 No Response 2 Historic 28
AI Classification
Action Taken 33%
Action Planned 39%
Noted 26%
Disputed 2%
Based on 46 classified responses
Top Categories
Hospital Death (Clinical Procedure… (22) Road (Highways Safety) related dea… (14) Other related deaths (8) Alcohol, drug and medication relat… (5) State Custody related deaths (4)
Quarterly Trend
Category Breakdown
How does this area compare?
vs East Midlands average: -2 reports · -8pp response rate
vs national average: -17 reports · -8pp response rate
67 results
Ashley Holden
All Responded
2020-0096 17 Apr 2020
Department for Transport Health and Safety Executive
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary (AI summary) Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of unsafe practices and fatalities from falling bales.
Noted (AI summary) HSE acknowledges the concerns and highlights existing guidance and enforcement approaches related to vehicle loading and workplace safety, particularly regarding bales. They will consider improvements to guidance INDG125 during its next periodic review. The DVSA will update the 'Load Securing - Vehicle Operators Guidance' in collaboration with HSE, focusing on generic safe loading principles rather than specific bale/trailer combinations. The DfT Code of Practice, 'Safety Loads on Vehicles' (2002) will be amended to cross-reference the updated guidance.
Millie Taylor-Noonan
All Responded
2020-0097 15 Apr 2020
Lincolnshire County Council Highways De…
Road (Highways Safety) related deaths
Concerns summary (AI summary) Inadequate pedestrian safety measures near a school crossing, including a lack of lighting, railings, dedicated crossings, crossing patrols, or temporary speed limits, creates a high-risk environment for students.
Action Taken (AI summary) Lincolnshire County Council will install street lighting as an exceptional case, improve road markings including SLOW and yellow SCHOOL zig-zag markings, install additional school warning signs, and provide school amber flashing lights. The school has also provided a teacher to marshal students at the school gate.
Donald Elliott
All Responded
2020-0109 12 Feb 2020
Glenholme Holdingham Grange Care Home
Care Home Health related deaths Other related deaths
Concerns summary (AI summary) Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises concerns about adequate care provision.
Action Taken (AI summary) Holdingham Grange Nursing Home investigated the circumstances around a resident's fall, finding sufficient staffing levels were in place, staff receive training, and no summons to the inquest were received. They have reviewed all falls risk assessments and are working with OTs, and falls training is available for all staff.
Darren Wilson
Historic (No Identified Response)
2019-0418 5 Dec 2019
Lincolnshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing to numerous near misses and non-fatal collisions.
Helen Barker
Historic (No Identified Response)
2019-0392 19 Nov 2019
CAT East Midlands Ambulance Service
Alcohol, drug and medication related deaths Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are exceeded, and inadequate contact with NHS 111 for unassessed C3 calls.
Matthew Bilby
All Responded
2019-0112 7 Mar 2019
Department for Transport Lincolnshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due to its layout and lack of traffic calming measures.
Noted (AI summary) The Department for Transport states that responsibility for traffic management on local roads rests with the local highway authority, and their role is to provide overarching strategy, policy, and guidance. They provide links to relevant guidance documents. The council states that there is currently no funding available for a roundabout project. Average speed cameras have reduced speeding offences, and the junction has been re-assessed with a lower priority ranking.
Terence Penney
Historic (No Identified Response)
2019-0034 28 Jan 2019
Glen Dimplex Home Appliances Ltd LEC Refrigeration Office for Product Safety and Standards
Product related deaths
Concerns summary (AI summary) A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar units in circulation.
Olive Johnson
All Responded
2019-0031 24 Jan 2019
East Midlands Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary) Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting times upon call regrading.
Action Planned (AI summary) EMAS acknowledges exceeding response times and states that additional funding was agreed to address this. The funding will be used for clinical staff, ambulances, and other resources to improve response times and consistency across the East Midlands.
Gail Bailey
Historic (No Identified Response)
2019-0027 23 Jan 2019
United Lincolnshire Hospitals NHS Trust
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.
Peter Lett
All Responded
2018-0356 28 Aug 2018
Health and Safety Executive
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded and dangerous, creating a high probability of further deaths.
Action Planned (AI summary) The HSE acknowledges the need to engage with voluntary organizations and volunteers and improve signposting to relevant guidance so they have a better understanding of their duties. They are actively working to improve web pages and develop further guidance and support networks for voluntary organizations including assisting them in finding bespoke guarding and risk control solutions to include heritage machinery.
Harry Jellicoe
Historic (No Identified Response)
2018-0108 18 Apr 2018
Lincolnshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring high-sided vehicles to use the center, exacerbated by a lack of priority signage.
Dorothy Breislin
All Responded
2017-0348 4 Dec 2017
Lincolnshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.
Action Planned (AI summary) The Trust is implementing a new SI process which incorporates training across the Trust and a new Risk Manager will start in February 2018. The updated clerking proforma risk assessment will be sent to stores to be re-printed and then circulated to the clinical teams.
Liam Oldsworth
Historic (No Identified Response)
2017-0301 20 Oct 2017
United Lincolnshire Hospital
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.
Ruth Milne
Partially Responded
2017-0156 16 May 2017
Lincolnshire Community Health Service N… Lincolnshire Register Office
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.
Action Taken (AI summary) Lincolnshire Community Health Services reports on actions taken following a safeguarding report, including establishing leg ulcer clinics, integrating specialist nurses, reviewing caseloads, and providing training on leg ulcer care and safeguarding. An action plan tracker has also been introduced.
Joan Green
All Responded
2016-0383 24 Oct 2016
Lincolnshire County Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." There were also significant delays for HGVs attempting to turn safely.
Action Planned (AI summary) National Highways will complete a study considering collisions between Toll Bar Road and Gonerby Moor to identify cost-effective remedial measures, which may include engineering, education, or enforcement in partnership with the Lincolnshire Road Safety Partnership. Action identified will be submitted for funding in the Spring/Summer.
Robert Dearing
Historic (No Identified Response)
2016-0311 30 Aug 2016
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary) Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification for these devices poses a safety risk.
Sidney Alexander
Historic (No Identified Response)
2016-0257 18 Jul 2016
United Lincolnshire Hospitals NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.
Sheila Slater
All Responded
2016-0127 31 Mar 2016
Department for Transport
Road (Highways Safety) related deaths
Concerns summary (AI summary) The staggered junction of the A16 with the B1166 is part of the Crowland Bypass which was pened in 2010 and there have been 3 fatalities associated with this junction and 10 injury producing collisions.
Noted (AI summary) The Department refers to existing design standards and notes the local authority is responsible for road safety. Highways England has been undertaking a scoping study with a view to updating the design guidance.
Derrick Twiate
Historic (No Identified Response)
2016-0079 29 Feb 2016
Dispensing Doctors Association Royal Pharmaceutical Society
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.
David Palmer
Historic (No Identified Response)
2016-0076 25 Feb 2016
Lincolnshire Police
Other related deaths
Concerns summary (AI summary) Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution might encourage their removal.
Arenijus Nedzelskies
Partially Responded
2016-0010 13 Jan 2016
Driver and Vehicle Licensing Agency Home Office
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.
Action Taken (AI summary) The Home Office highlights that the Psychoactive Substances Act 2016 restricts the production, supply and importation of psychoactive substances, and notes over 500 new drugs have already been banned. It also mentions toolkits and clinical guidelines for psychoactive substance use.
Mark Holdsworth
Historic (No Identified Response)
2016-0003 4 Jan 2016
Lincolnshire Police
Other related deaths
Concerns summary (AI summary) Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.
Stuart Knight
All Responded
2015-0385 22 Sep 2015
East Midlands Ambulance Services
Community health care and emergency services related deaths
Concerns summary (AI summary) Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.
Action Taken (AI summary) EMAS has increased its frontline resources, implemented a 'hear and treat' system, and introduced a single Ambulance Technician vehicle in East Lincolnshire. These initiatives aim to increase ambulance availability for high clinical need cases.
Rubel Ahmed
Partially Responded
2015-0308 5 Aug 2015
Home Office Ministry of Justice
State Custody related deaths
Concerns summary (AI summary) Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions was not shared.
Noted (AI summary) The Home Office acknowledges the concerns regarding the death at Morton Hall IRC. They explain the challenges of unlocking rooms overnight, the existing practices for detention awareness, and the use of electrical items, but offer no concrete action.
Lynn Poyser
Historic (No Identified Response)
2015-0295 23 Jul 2015
Lincolnshire Community Health Services Medicines and Healthcare products Regul… National Institute for Health and Care …
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.